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Deficiency Records for Continuing Healthcare at Willow Haven
A list of the most recent deficiencies for Continuing Healthcare at Willow Haven. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Continuing Healthcare at Willow Haven. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-08 | 2024-08-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-24 | 2024-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-24 | 2024-07-12 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-03-28 | 2024-04-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-28 | 2024-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-28 | 2024-04-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-28 | 2024-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-28 | 2024-04-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-03-28 | 2024-04-11 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-03-28 | 2024-04-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-28 | 2024-04-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-28 | 2024-04-11 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-28 | 2024-04-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-28 | 2024-04-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-26 | 2024-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-26 | 2024-04-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-26 | 2024-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-26 | 2024-04-11 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-11-15 | 2023-11-17 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-18 | 2023-06-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-18 | 2023-06-13 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-05-18 | 2023-06-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-18 | 2023-06-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | 2023-06-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-18 | 2023-06-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-05-18 | 2023-06-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-18 | 2023-06-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-18 | 2023-06-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-18 | 2023-06-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-18 | 2023-06-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-18 | 2023-06-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-17 | 2023-06-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-17 | 2023-06-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-06-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-17 | 2023-06-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-17 | 2023-06-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-19 | 2023-05-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-19 | 2023-05-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-19 | 2023-05-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-19 | 2023-02-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-19 | 2023-02-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-19 | 2023-02-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-18 | 2022-11-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-18 | 2022-11-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-08-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-04 | 2022-08-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-04 | 2022-08-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-04 | 2022-08-30 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-24 | 2022-04-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-31 | 2022-04-01 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-30 | 2022-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2022-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-06 | 2021-10-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-06 | 2021-08-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-06 | 2021-08-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-06 | 2021-08-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-06 | 2021-08-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-07-06 | 2021-08-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-06 | 2021-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-06 | 2021-08-06 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-30 | 2021-08-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-30 | 2021-08-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-30 | 2021-08-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-30 | 2021-08-06 | N |
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